People Googling for ACA coverage often found results that were actually trying to sell them skimpier short-term health plans, according to a report from Robert Wood Johnson Foundation and the Urban Institute.

Why it matters: Consumer confusion is one of the things regulators worried about most when the Trump administration expanded access to “short-term” coverage.

For some people, especially those who do only need coverage for a short time, one of these more bare-bones options might be a better choice than the comprehensive policies sold under the ACA.

But if you don’t realize you’re signing up for a plan with incredibly limited coverage and the right to drop you once you get sick, you could be in for a catastrophic surprise.

Details: Researchers Googled terms including “cheap health insurance” and “Obamacare plans” and looked at the first 4 results — which are usually ads.

Sites that included short-term plans “dominated the results,” though some of those sites also sell ACA-compliant plans. Sites varied in how much information they provided about the differences between the two types of plans.

The powerful House Ways and Means Committee used its first policy hearing of the new Congress to hammer Republicans on pre-existing conditions, an issue that helped propel Democrats into the majority during the 2018 midterm elections.

Democratic panel members highlighted actions by the Trump administration that they argue have hurt people with pre-existing conditions, like the expansion of non-ObamaCare plans that could draw healthy people from the markets, raising premiums for those left behind.

The administration has expanded access to association and short-term health plans, which cost less than ObamaCare plans but cover fewer services. Republicans say they provide an off-ramp for consumers who can’t afford ObamaCare plans.

The witness invited by Republicans, Rob Robertson with the Nebraska Farm Bureau, said its newly developed association health plan “meets the needs of our members,” who can’t afford ObamaCare plans.

“We’re in this for the long term,” he told lawmakers. “We want to reduce costs, and the costs in the individual market are very, very high.”

ObamaCare’s popular consumer protections became the centerpiece of the November midterms after 20 Republican-led states sued to overturn the 2010 health care law, known as the Affordable Care Act (ACA).

Democrats tied congressional Republicans to the lawsuit after the Trump administration declined to defend ObamaCare and argued that those protections are unconstitutional.

Republicans say there are different ways to cover people with pre-existing conditions, like high-risk pools, which were banned after ObamaCare was implemented. Some pools had caps on coverage and long-waiting lists.

GOP committee members called Tuesday’s hearing political theatre, arguing they also support pre-existing protections but want to lower ObamaCare’s costs.

“Everyone up here wants protections for people with pre-existing conditions. Always have, always will,” said Rep. Devin Nunes (R-Calif.), ranking member of the health subcommittee. “We should be careful that we’re not stoking fear that someone is going to lose their health insurance. We have a responsibility to come up with a better health care system because ObamaCare is not the solution.”

Democrats on Tuesday said the GOP proposals aren’t serious.

Republicans have “political amnesia” and have “forgotten what it was like before the ACA,” said Rep. Lloyd Doggett (D-Texas), chairman of the health subcommittee. “Those with a diagnosis of a serious disease would also get a diagnosis of financial ruin. There were no protections for them before the ACA.”

Some Democratic panel members appealed to the emotional side of the health care debate, with one lawmaker announcing her cancer diagnosis at the hearing.

“This is a cancer I will live with for the rest of my life, but, because of my high-quality healthcare and insurance coverage, it is not a cancer I will die from,” said Rep. Gwen Moore (D-Wis.), 67.

Tensions ran high at times during Tuesday’s hearing, with members re-litigating the 2010 passage of ObamaCare and repeated GOP efforts to repeal it.

“Not one Republican up here supports pre-existing protections for the American people,” said Rep. Brian Higgins (D-N.Y.), who at times pounded his fist on the dais.

That drew a testy response from Rep. Tom Reed (R-Pa.), who said Republicans “heard the voices and the fear” from voters in the 2018 midterms when “this issue became the centerpiece.”

A lawsuit that threatens to kill the entire Affordable Care Act could be a political disaster for the GOP, but most Republicans aren’t trying to stop it — and some openly want it to succeed.

Between the lines: The GOP just lost the House to Democrats who campaigned heavily on health care, particularly protecting people with pre-existing conditions, but the party’s base still isn’t ready to accept the ACA as the law of the land.

The big picture: A district judge ruled last month that the ACA’s individual mandate is unconstitutional and that the whole law must fall along with it. That decision is being appealed.

A victory for the Republican attorneys general who filed the lawsuit — or for the Trump administration’s position — would likely cause millions of people with pre-existing conditions to lose their coverage or see their costs skyrocket.

Some Republicans want the lawsuit to go away.

Rep. Greg Walden, ranking member of the Energy and Commerce Committee, supports fully repealing the ACA’s individual mandate, which the 2017 tax law nullified. That’s what sparked this lawsuit, and formal repeal would likely put the legal challenge to rest.

Sen. Susan Collins laughed when I asked her whether she hopes the plaintiffs win the case. “No. What a question,” she said.

But other Republicans say they see an opportunity.

If the lawsuit prevails, “it means that we could rebuild and make sure that we have a health care system that is going to ensure that individuals are in charge of their health care,” Rep. Cathy McMorris Rodgers said.

Sen. David Perdue said that “of course” he wants the challengers to win, which would “give us an opportunity to get at the real problem, and that is the cost side of health care.”

Sen. Shelley Moore Capito said she views the lawsuit “as an opportunity for us to assure pre-existing conditions and make sure that we fix some of the broken problems,” but that she doesn’t know if it’d be good if the plaintiffs win.

The bottom line: “The longer we’re talking about preexisting conditions, the longer we’re losing. We need to focus on a message that can win us voters in 2020. The debate of preexisting conditions was a stone-cold loser for us in 2018,” said Matt Gorman, the communications director for House Republicans’ campaign arm during the 2018 cycle.

Between the fiercely competitive midterm elections and ongoing upheaval over the Trump administration’s immigration policies, 2018 was no less politically tumultuous than 2017. The same was true for the world of health care. Republicans gave up on overt attempts to repeal and replace the Affordable Care Act (ACA) through legislation, but the administration’s executive actions on health policy accelerated. Several states took decisive action on Medicaid and some of the struggles over the ACA made their way to the courts. Drug prices remain astronomically high, but public outrage prompted some announcements to help control them. At the same time, corporate behemoths made deeper inroads into health care delivery, including some new overtures from Silicon Valley. Here’s a refresher on some of the most notable events of the year.

1. The ACA under renewed judicial assault

Texas v. Azar, a suit brought by Texas and 19 other Republican-led states, asked the courts to rule the entire ACA unconstitutional because Congress repealed the financial penalty associated with the individual mandate to obtain health insurance that was part of the original law. District Judge Reed O’Connor ruled in favor of the plaintiffs, creating confusion at the end of the ACA’s open enrollment period, and setting up what may be a years-long judicial contest (yet again) over the constitutionality of the ACA. To learn more about the legal issues at stake, see Timothy S. Jost’s recent To the Point post.

2. Turnout for open enrollment in health insurance marketplaces surged at the end of the sign-up period

The federal and state-based marketplaces launched their sixth enrollment season on November 1 for individuals seeking to buy health coverage in the ACA’s individual markets for 2019. Insurer participation remained strong and premiums fell on average. While some states have extended enrollment periods, HealthCare.gov, the federal marketplace, closed on December 15. After lagging in the early weeks, enrollment ended just 4 percent lower this year than in 2017.

3. The administration continues efforts to hobble ACA marketplaces

While the reasons behind lower enrollment cannot be decisively determined, executive action in 2018 may have contributed. The Trump administration dramatically cut back federal investments in marketplace advertising and consumer assistance for the second year in a row. The federal government spent $10 million on advertising for the 34 federally facilitated marketplaces this year (the same as last year but an 85 percent cut from 2016) and $10 million on the navigator program (down from $100 million in 2016), which provides direct assistance to hard-to-reach populations.

4. Insurers encouraged to sell health plans that don’t comply with the ACA

Another tactic the Trump administration is using to undercut the ACA is increasing the availability of health insurance products, such as short-term health plans, that don’t comply with ACA standards. Short-term plans, previously available for just three months, can now provide coverage for just under 12 months and be renewed for up to 36 months in many states. These plans may have gaps in coverage and lead to costs that consumers may not anticipate when they sign up. By siphoning off healthy purchasers, short-term plans and other noncompliant products segment the individual market and increase premiums for individuals who want to — or need to — purchase ACA-complaint insurance that won’t discriminate against people with preexisting conditions, for example.

5. Medicaid expansion in conservative states

Few states have expanded Medicaid since 2016, but in 2018, a new trend toward expansion through ballot initiatives emerged. Following Maine’s citizen-initiated referendum last year, Idaho, Nebraska, and Utah passed ballot initiatives in November to expand Medicaid. Other red states may follow in 2019. Medicaid expansion not only improves access to care for low-income Americans, but also makes fiscal sense for states, because the federal government subsidizes the costs of newly eligible Medicaid enrollees (94 percent of the state costs at present, dropping to 90 percent in 2020).

6. Red states impose work requirements for Medicaid

A number of states submitted federal waivers to make employment a requirement for Medicaid eligibility. Such waivers were approved in five states — Arkansas, Kentucky, Wisconsin, New Hampshire, and Indiana — and 10 other states are awaiting approval. At the end of 2018, lawsuits are pending in Arkansas and Kentucky challenging the lawfulness of work requirements for Medicaid eligibility. About 17,000 people have lost Medicaid in Arkansas as a result of work requirements.

7. Regulatory announcements respond to public outrage over drug prices

Public outrage over prescription drug prices — which are higher in the U.S. than in other industrialized countries — provided fodder for significant regulatory action in 2018 to help bring costs under control. Of note, the Food and Drug Administration announced a series of steps to encourage competition from generic manufacturers as well as greater price transparency. The U.S. Department of Health and Human Services in October announced a proposed rule to test a new payment model to substantially lower the cost of prescription drugs and biologics covered under Part B of the Medicare program.

9. Growth in health spending slows

The annual report on National Health Expenditures from the Centers for Medicare and Medicaid Services estimates that in 2017, health care spending in the U.S. grew 3.9 percent to $3.5 trillion, or $10,739 per person. After higher growth rates in 2016 (4.8%) and 2015 (5.8%) following expanded insurance coverage and increased spending on prescription drugs, health spending growth has returned to the same level as between 2008 to 2013, the average predating ACA coverage expansions.

10. Drug overdose rates hit a record high

Continuing a tragic trend, drug overdose deaths are still on the rise. The Centers for Disease Control and Prevention reported 70,237 fatalities in 2017. Overdose deaths are higher than deaths from H.I.V., car crashes, or gun violence, and seem to reflect a growing number of deaths from synthetic drugs, most notably fentanyl. 2018 was the first year after President Trump declared the opioid crisis a public health emergency. National policy solutions have so far failed to stem the epidemic, though particular states have made progress.

As we slip into 2019, expect health care issues to remain front and center on the policy agenda, with the administration continuing its regulatory assault on many key ACA provisions, Democrats harassing the executive branch with House oversight hearings, both parties demanding relief from escalating pharmaceutical prices, and the launch of health care as a 2020 presidential campaign issue.

Sure, they’re less expensive for consumers, but short-term health policies have another side: They’re highly profitable for insurers and offer hefty sales commissions.

Driven by rising premiums for Affordable Care Act plans, interest in short-term insurance is growing, boosted by Trump administration actions to ease Obama-era restrictions and possibly make federal subsidies available to consumers to purchase them.

That’s good news for brokers, who often see commissions on such policies hit 20 percent or more.

On a policy costing $200 a month, for example, that could translate to a $40 payment each month. By contrast, ACA plan commissions, which are often flat dollar amounts rather than a percentage of premium, can range from zero to $20 per enrollee per month.

“Customers are paying less and I’m making more,” said Cindy Holtzman, a broker in Woodstock, Ga., who said she gets 20 percent on short-term plan commissions.

Large online brokers also are eagerly eyeing the market.

Ehealth, one such firm, will “continue to shift our focus to selling short-term plans and non-ACA insurance packages,” CEO Scott Flanders told investors in October. The firm saw an 18 percent annual jump in enrollment in short-term plans this year, he added.

Insurers, too, see strong profits from plans because they generally pay out very little toward medical care when compared with the more comprehensive ACA plans.

Still, some agents like Holtzman have mixed feelings about selling the plans, because they offer skimpier coverage than ACA insurance. One 58-year-old client of Holtzman’s wanted one, but he had health problems. She also learned his income qualified him for an ACA subsidy, which currently cannot be used to purchase short-term coverage.

“There’s no way I would have considered a short-term plan for him,” she said. “I found him an ACA plan for $360 a month with a reduced deductible.” (A federal district court judge in Texas issued a ruling Dec. 14 striking down the ACA, which would among other things impact the requirements of ACA coverage and subsidies. The decision is expected to face appeal.)

Short-term plans can be far less expensive than ACA plans because they set annual or lifetime payment limits. Most exclude people with medical conditions, they often don’t cover prescription drugs, and policies exclude in fine print some conditions or treatments. Injuries sustained in school sports programs, for example, often are not covered. (These plans can be purchased at any time throughout the year, which is different than plans sold through the federal marketplaces. The open enrollment period for those ACA plans in most states ends Dec. 15.)

Consequently, insurers providing short-term plans don’t have to pay as many medical bills, so they have more money left over for profits. In forms filed with state regulators, Independence American Insurance Co. in Ohio shows it expects 60 percent of its premium revenue to be spent on its enrollees’ medical care. The remaining 40 percent can go to profits, executive salaries, marketing and commissions.

A 2016 report from the National Association of Insurance Commissioners showed that, on average, short-term plans paid out about 67 percent of their earnings on medical care.

That compares with ACA plans, which are required under the law to spend at least 80 percent of premium revenue on medical claims.

Short-term plans have long been sold mainly as a stopgap measure for people between jobs or school coverage. While exact figures are not available, brokers say interest dropped when the ACA took effect in 2014 because many people got subsidies to buy ACA plans and having a short-term plan did not exempt consumers from the law’s penalty for not carrying insurance.

But this year it ticked up again after Congress eliminated the penalty for 2019 coverage. At the same time, the premiums for ACA plans rose on average more than 30 percent.

“If I don’t want someone to walk out of the office with nothing at all because of cost, that’s when I will bring up short-term plans,” said Kelly Rector, president of Denny & Associates, an insurance sales brokerage in O’Fallon, a suburb of St. Louis. “But I don’t love the plans because of the risk.”

The Obama administration limited short-term plans to 90-day increments to reduce the number of younger or healthier people who would leave the ACA market. That rule, the Trump administration complained, forced people to reapply every few months and risk rejection by insurers if their health had declined.

This summer, the administration finalized new rules allowing insurers to offer short-term plans for up to 12 months — and gave them the option to allow renewals for up to three years. States can be more restrictive or even bar such plans altogether.

Administration officials estimate short-term plans could be half the cost of the more comprehensive ACA insurance and draw 600,000 people to enroll in 2019, with 100,000 to 200,000 of those dropping ACA coverage to do so.

And recent guidance to states says they could seek permission to allow federal subsidies to be used for short-term plans. Currently, those subsidies apply only to ACA-compliant plans.

Granting subsidies for short-term plans “would mean tax dollars are not only subsidizing commissions, but also executive salaries and marketing budgets,” said Sabrina Corlette of Georgetown University Center on Health Insurance Reforms.

No state has yet applied to do that.

For now, brokers are focusing on getting their clients into some kind of coverage for next year. Commissions on both ACA and short-term plans are getting their attention.

After several years of declining commissions for ACA plans — with some carriers cutting them altogether a couple of years ago — brokers say they are seeing a bit of a rebound.

Among Colorado ACA insurers, “it’s gone from about $14 to $16 per enrollee [a month] to $16 to $18,” said Louise Norris, a health policy writer and co-owner of an insurance brokerage.

Rector, in Missouri, said an insurer that last year paid no commissions has reinstated them for 2019 coverage. For her, that doesn’t really matter, she said, because once carriers started reducing or eliminating commissions, she began charging clients a flat rate to enroll.

Norris noted that some states changed their laws so brokers could do just that.

At least one state, Connecticut, ruled that insurers had to pay a commission, which she thinks is protective for consumers.

“Insurance regulators need to step in and make sure brokers are getting paid,” said Norris, or some brokers, “out of necessity,” might steer people to higher-commission products, such as short-term plans, that might not be the best answer for their clients.

Her agency does not sell short-term or some other types of limited-benefit plans.

“I don’t want to have a client come back and say I’ve had a heart attack and have all these unpaid bills,” she said.

Obamacare is precarious yet entrenched as 2019 approaches. Even many of the GOP-led states seeking to knock it down in court would be in a real bind should they succeed.

Of the 20 states involved in a high-profile Texas-led lawsuit arguing the Affordable Care Act is unconstitutional, nearly half have already accepted its extra dollars to expand their Medicaid programs or are moving that direction. States don’t have to expand Medicaid under a 2012 Supreme Court decision, but most have found it advantageous because the federal government foots most of the bill.

These states — nine in total — would suddenly be facing a much larger expense for hundreds of thousands of low-income earners newly enrolled in Medicaid under the ACA, should last week’s decision by U.S. District Judge Reed O’Connor rolling back the entire health-care law ultimately stand.

They include Louisiana, North Dakota and West Virginia, along with Arizona, Arkansas and Indiana, three states that expanded Medicaid but with some modifications. In three other states — Maine, Nebraska and Utah — voters approved ballot initiatives adopting expansion.

Yet these states are asking the courts to overthrow not just Obamacare’s protections for people with preexisting conditions – the part of the lawsuit that has gotten the most attention — but also the entire sweeping law, which is now firmly a part of the country’s health-care ecosystem eight years since its passage. More than 12 million people have become eligible for Medicaid since ACA passage, while another 11 million have enrolled in the ACA’s federally subsidized private marketplaces.

“God help us all, because the dark age is not that far from us again,” said Sen. Joe Manchin (D-W.Va.). “It will be worse than before because there won’t be the money to help rural clinics and hospitals.”

Developments in the past week — including the court ruling and slightly lagging marketplace enrollment figures released yesterday by the Trump administration — underscore the political divides dogging Obamacare even though Republicans in Congress and at the state level have embraced some of its major components.

Nearly 8.5 million people signed up for 2019 plans in the 39 states using the HealthCare.gov website (the other states run their own marketplaces), per figures from the Centers for Medicare and Medicaid Services. Enrollment was just 4 percent less than a year ago, due to a last-minute rush that suggests consumers were undeterred by the court ruling, our Washington Post colleague Amy Goldstein reports.

“After lagging by about 11 percent most of the six weeks of open enrollment — a shortened period adopted by the Trump administration a year ago — the more than 400,000 who selected coverage during the final week actually exceeded the year before,” Amy writes.

CMS Administrator Seema Verma seemed unperturbed by the reduced enrollment numbers, saying they merely show new GOP and administration policies to roll back some ACA requirements on insurers and consumers are working.

But if the entire law gets scrapped by the Supreme Court ( we should note, the case still has a long way to go in the legal system), it will quickly become clear the ACA — for whatever its faults — has extended benefits to Americans they’ve now come to expect. Despite their persistent rhetoric against the law, Republicans have found it politically necessary to embrace big parts of it, including its protections for people with preexisting conditions — and, in some states, its Medicaid expansion.

Case in point: West Virginia. Its Republican attorney general, Patrick Morrisey, has joined the lawsuit against Obamacare even though the state embraced its Medicaid expansion, growing its enrollment in the program by nearly one-third.The federal government covers more than 90 percent of the cost of the newly eligible enrollees.

When I asked Morrisey’s office about what striking the ACA would mean for Medicaid recipients, his office provided a statement praising O’Connor’s ruling and discussing premium hikes in the marketplaces — but didn’t mention Medicaid.

“Our nation must move beyond Obamacare, innovate, provide more choices to consumers, and attack the skyrocketing premiums that have caused such pain and hardship on West Virginian and American families,” the statement said.

In some cases, the decisions by state attorneys general to join the anti-ACA lawsuit has put them at odds with their governor. Louisiana’s Democratic governor, John Bel Edwards, moved quickly to expand Medicaid when he took office in 2016. Nearly half a million people have enrolled in Medicaid since then, growing the state’s program by 27 percent.

Edwards hasn’t hidden his disdain for Louisiana Attorney General Jeff Landry (R), who has called the law an “unconstitutional overreach.” Edwards issued a critical statement after last Friday’s decision.

“This was a short-sighted lawsuit, to say the least,” Edwards said in a statement. “I intend to vigorously pursue legislation to protect individuals with pre-existing conditions from losing their health insurance and ensuring the working people of our state aren’t penalized because of this decision.”